building on our foundation 2011-2016 - northwest territories · building on our foundation 2011-...

Building on Our Foundation

2011-2016A Strategic Plan for the NWT Health and Social Services System

August 2011 | www.hlthss.gov.nt.ca

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Message from the MinisterBuilding on our Foundation is a five year strategic plan for the Northwest Territories (NWT) Health and Social Services system and builds on the foundation established by our last action plan: A Foundation for Change. The Joint Leadership Council (JLC) for the Health and Social Services (HSS) system is committed to providing leadership, direction and guidance for an integrated system that will improve the health and well-being of all northerners. The JLC

has provided guidance and direction in developing this document.

Building on our Foundation provides a road map for the next five years and establishes the direction for delivery of integrated and seamless territorial and regional health and social services. It identifies high-level actions that will be supported through annual business plans and includes deliverables and targets that will hold the Minister, JLC and the Joint Senior Management Committee (JSMC) of the Health and Social Services system accountable.

Health and Social Services is a complex, high-risk business. It must respond appropriately to and balance the needs of individuals, families, communities as well as the system as a whole. While the current standard of services and care that people of the NWT receive is excellent, we must always strive for ongoing improvement, enhanced efficiencies and maximized use of new technologies to best respond to the needs of the population.

Through our last strategic plan we have had many achievements and have made significant progress through Foundation for Change and other key initiatives aimed at improving the system and the lives of people. Many of these initiatives required extensive planning and will soon be ready for implementation. However, we are consistently challenged to provide effective

and efficient high quality services that meet public expectations and are focused on patient safety and positive outcomes. We continue to face challenges ensuring families are healthy and children, particularly those at risk, are safe, nurtured and given the best possible developmental opportunities. We are now at a tipping point and need to make changes in the way our system is managed, operated and funded. Individuals must also make changes and take responsibility for ensuring their own health and well-being.

We are challenged by issues that other jurisdictions do not even contemplate as many of our residents live in small isolated communities. Providing services to remote communities requires a medical travel system that links people to services not available locally and acts as an air ambulance in emergencies. The plan identifies ways to ensure patients receive appropriate services in an efficient and effective manner while adhering to policy. The plan’s initiatives further support the improvement of services in remote communities by employing new technologies such as tele-health, digital x-rays, an online patient record system – all targeted at providing a higher quality service while reducing overall system costs.

Another important priority is managing resources in the best way possible to achieve positive health outcomes for clients and patients. To be sustainable we will strive to ensure the system has the right mix of health professionals to provide services that will meet the needs of our residents now and into the future. We have invested in training northern nurses, social workers, home care nurses, mental health workers and other allied health professionals. We will continue to train northerners and encourage our youth to pursue careers in health and social services. We need to ensure our employees have a safe work environment and are appropriately supported by information management systems, technologies and physical infrastructure to deliver high quality services as efficiently as possible.

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One of our top priorities will be to strengthen the delivery of primary care in the community as it is key to realizing efficiencies and improving outcomes. We can do this by ensuring our primary care providers are making progress on important issues such as managing chronic conditions and integrating mental health and addiction services into the larger health system. We will improve quality of health care, manage costs and address recruitment and retention in remote communities through a territorial support centre for front line care providers in small communities. The territorial support network will provide community care providers with access to shared expertise that can provide advice and guidance on patient care, potentially reducing the need for emergency medical evacuations. The support center will also ensure that consistent care standards and protocols are followed. Providing this support will ensure the best possible outcome for patients.

We recognize that change cannot happen in a day or even a year, it will take years to see the effects of these changes. We alone cannot improve health outcomes, we all have a role to play when it comes to our health. This includes accepting responsibility as individuals for maintaining our own good health through actions like proper diet and exercise, providing a safe nurturing home for our children, or by stopping smoking and excessive use of alcohol. Communities play an important role in working with providers to develop services and supports that will help residents in achieving a well balanced lifestyle.

The next few years are sure to bring significant challenges to service delivery and we have every confidence that we can respond to these challenges and continue to provide quality health care and social services consistent with GNWT priorities and the needs of the population. The course ahead will require courage and conviction, innovation, flexibility, adaptation and continued support for change and for making the best use of our limited

resources including each person’s personal responsibility as a contributor to healthy communities and a healthy territory.

J. Michael Miltenberger Minister of Health and Social Services

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Table of ContentsIntroduction ..................................................................................................................5

Overview ........................................................................................................................6

Vision, Mission and Guiding Principles ..............................................................7

Goals ...............................................................................................................................7

Strategic Priorities ......................................................................................................8

Moving Forward ...................................................................................................... 10

Priority 1: Enhance services for children and families .............................11

Priority 2: Improve the health status of the population .........................16

Priority 3: Deliver core community health and social services through innovative service delivery ......................................... 20

Priority 4: Ensure one territorial integrated system with local delivery ......................................................................... 25

Priority 5: Ensure patient/client safety and system quality .................. 28

Priority 6: Outcomes of health and social services are measured, assessed and publicly reported ................................................ 31

5Building on Our Foundation 2011- 2016A Strategic Plan for the NWT Health and Social Services System

IntroductionIt has been five years since the last comprehensive system strategic plan: Shaping Our Future 2006-2010, and two years since the publication of our last action plan: A Foundation for Change, which identified initiatives needed to begin the reform of the system. These high-level reform initiatives continue into our new five year strategic plan: Building on Our Foundation.

While health and social services and its partners have leadership roles in addressing health and social issues, the well-being of individuals, families, and communities also depends on factors beyond our mandate. The population health approach recognizes that demographic, economic, social and personal factors are all important determinants of health and well-being. Ultimately, everyone has a role to play in improving the overall health status of the population.

Effective and collaborative planning is essential to responding to existing and emerging issues. As demand for services and costs increase and competition for limited GNWT resources increases, a strategic approach to planning becomes essential to meet future challenges. Over the next five years, the Department of Health and Social Services and the Authorities will work together with other GNWT departments and agencies to effectively improve the health status of the residents of the NWT.

In order to address the needs of the population and achieve the best possible health and social outcomes, solutions need to be community based, community driven and culturally appropriate. In 2010, the Minister engaged in dialogues with communities. The Health Forum in Yellowknife provided decision-makers with an opportunity to discuss issues impacting on the future sustainability of the system. Further dialogues were conducted in each region with representation from communities. The groups represented included:

Aboriginal Governments, elders, youth, municipal leadership, women and Regional Health Authority Board members.

Feedback from the Regional Dialogues and JLC along with recommendations from the Office of the Auditor General’’s program review, and recommendations from the 16th Legislative Assembly Standing Committee on Social Programs (SCOSP) review of the report on the Child and Family Services Act set the framework for this plan.

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OverviewResidents of the NWT enjoy and expect a health and social services system that provides access to high quality services that are responsive to the needs of the population. HSS is committed to providing quality services in a way that makes the best use of public resources, ensures sustainability of the system, focuses on patient safety and best practices and promotes positive health and social outcomes.

In order to achieve positive health outcomes for the population we need long-term support, as government alone cannot improve the health of the population. A population health approach recognizes that measuring the health of the population needs to extend beyond an assessment of traditional health status indicators such as death, disease and disability. This approach considers factors such as mental and social well-being, quality of life, life satisfaction, income, access to employment and education attainment.

To improve the health and wellness of the population we will work in collaboration with relevant NGOs, other government departments, communities and the public. We will continue to work with Aboriginal leadership to foster an environment that supports healthy lifestyles and provides quality, community-based social services focusing on wellness of children and families.

The health and social services system is rooted in a primary community care approach intended to ensure clients receive appropriate, accessible, effective, quality care at the right time by the most appropriate provider. To be effective, social programs will be better integrated and linked to ensure the most appropriate services are provided to those individuals accessing the system. We will maximize the use of technology to increase linkages between patients and service providers in communities and provide high level support as required.

The system continues to experience increased demand for home and community care services. There is a growing reliance on this sector resulting from an increase in the level of patient acuity, an aging population, increasing rates of chronic disease, changing approaches to hospital care, increased out-patient procedures and rapid patient discharge from other jurisdictions. This has resulted in an increased need for follow-up care at home. We will work in partnership with others, including the NWT Housing Corporation and communities to ensure that communities and families are able to appropriately care for their loved ones at home where possible.

Our health system is high risk, complex and diverse and requires a high level of public spending. In order to maximize efficiencies, build capacity and manage risk, we will better coordinate services territorially, while still providing for regional service delivery. There is a growing demand for sound governance and accountability to the public. The challenge is to clarify roles, responsibilities, and accountability structures for all players, including the system governance arm, boards, service providers, as well as individuals and communities. In addition, there is an opportunity to improve the effectiveness of our system, quality of care and public confidence. We will set performance benchmarks and targets that measure progress towards achieving our goals and monitor progress through quality assurance and performance monitoring.

The NWT Health and Social Services system is committed to a quality system that is based on wellness, access, sustainability and accountability. The strategic directions identified in Building on our Foundation will guide the system to meet the needs of today’s population. Building on our Foundation will be reviewed and updated every year and be aligned and supported by the GNWT business planning process and budget cycle. To ensure we are held accountable for accomplishing what we have set out to do, we will report on the implementation of this plan through annual reporting on performance measures to the Legislative Assembly and the public.


Vision, Mission and Guiding PrinciplesVisionHealthy people, healthy families, healthy communities

MissionTo promote, protect and provide for the health and well-being of the people of the Northwest Territories

Guiding PrinciplesPersonal Responsibility– Individuals, families and communities have a lead role in achieving their own overall health and well-being

Collaboration– Working together to ensure individuals, families and communities make well informed decisions about their health and wellness

Core Need– Publicly funded programs and services that support basic health and social needs

Opportunities for Engagement– Community provides input/advice on health and social service matters affecting their community

Patient/Client Safety– Health and social services are delivered within acceptable practice and clinical standards

Transparency – Outcomes are measured, assessed and publicly reported

GoalsIn order to provide high quality health and social services we have established goals that support our vision, mission and guiding principles.

WellnessCommunities, families and individuals make healthy choices; children are raised in safe environments and are protected from injury and disease

AccessThe right service at the right time by the right provider

SustainabilityLiving within our means

AccountabilityReporting to the public and the Legislative Assembly

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Strategic PrioritiesTo ensure we make consistent progress towards our goals we developed the following strategic priorities focusing on individuals and families, communities and the administration of the health and social services system. These are targeted to our most pressing needs and issues and guide the development of our strategic objectives and actions. Our strategic objectives and actions will be operationalized in the annual business plans and may be adjusted as necessary to address emerging issues and challenges.

Priority 1: Enhance services for children and families – Consistent with national trends, more children and families in the NWT are seeking services and supports and the complexity of cases is increasing. This increased demand for services is further complicated by a shortage of qualified social workers and mental health workers in the NWT and an inability to recruit qualified foster parents that are able to provide culturally appropriate homes for children in care.

Parents are responsible for taking care of their children and making sure they are safe and healthy, however, there are times when families need additional support. To meet the needs of children and families, we will work with communities to develop community based plans to care for children in a way that is culturally appropriate and provides for community based supports and programming. The health and social services system is committed to working with communities in establishing Child and Family Service Committees to ensure that plans for children reflect community values and that every effort is made to keep children safe in their home communities. We will focus on the least intrusive approaches such as mediation rather than the use of the courts and on early intervention and working with parents to prevent child protection concerns from arising.

Priority 2: Improve the health status of the population – In the NWT, almost 70% of all deaths and more than 50% of days spent in hospital are related to chronic conditions. Being overweight or obese is also cause for concern, particularly for cardiovascular disease and diabetes. The proportion of our residents affected by diabetes is rising and is likely to continue to rise with approximately 200 new cases diagnosed in the NWT each year.

Another area of significant concern is the high incidence of mental health and addictions in the NWT. Mental health is a chronic condition and many individuals that live with mental health issues also have addictions issues and require access to a broad array of care options. Rates of substance abuse, suicide and alcohol related injuries are higher in the NWT than national averages. In 2009/10 approximately 1.4% of the population was hospitalized for a mental illness with more than half of these hospitalizations being related to substance abuse – primarily alcohol-related. Statistics indicate that individuals seeking treatment for addictions have a high relapse rate, and often require many rounds of treatment before achieving any measure of success.

The potential for improved population health is maximized by targeting programs and prevention efforts to those individuals most in need. We will need to work with communities, partners and individuals to ensure we provide integrated, culturally appropriate programming that builds on the existing capacities and resources in the communities.

9Building on Our Foundation 2011- 2016A Strategic Plan for the NWT Health and Social Services System 9

Priority 3: Deliver core community health and social services through innovative service delivery – The Integrated Service Delivery Model (ISDM) recognizes that not every service can be available in every community; however, core or basic health and social services need to be accessible as close to where people live as possible. Primary community care is the first point of entry for individuals to the health care system. This is where health services (including mental health) are mobilized and coordinated to promote wellness, prevent trauma and illness, build capacity, provide support and care for common health and wellness issues. Through innovative service delivery we will ensure people have the majority of their health and social needs met by high quality community-based support and care. This will be accomplished through the use of technology to maximize rural/remote access to limited specialized resources.

Priority 4: Ensure one territorial integrated system with local delivery – Health and social services systems are high risk, complex and diverse and require a high level of public spending – this is the case in the NWT as well. Residents of the NWT expect a consistent level of services across regional boundaries and expect to move across these boundaries when necessary without issue. In addition, NWT residents expect sound governance practices and a clear accountability processes. Residents expect to have a health and social services system that is sustainable, accessible, community-based and affordable. In order to maximize efficiencies, build capacity and manage risk we need to better coordinate services territorially, while still providing for regional service delivery. Further, leadership will require the skills to manage risk, the flexibility to support system-wide change for best practices and function as one system.

Priority 5: Ensure patient/client safety and system quality – Ensuring the quality of our services and keeping patients and clients safe is vital in all areas of the health and social services system. We need to focus on the fundamentals of high quality, safe services with continual quality improvement to achieve positive outcomes in all areas of the system. The long-term outcomes associated with this priority are that NWT residents will have access to sustainable, safe, community based health and social services.

Priority 6: Outcomes of health and social services are measured, assessed and publicly reported – Public accountability is one of the basic principles of the health and social services system. Individuals responsible for the management and delivery of health care and social services face immense challenges to ensure all residents receive high quality care in a timely and sustainable manner. Measurement and reporting will guide providers and the system to ensure best practice and ongoing quality improvement to ensure the best quality and safe care. The consumers of our programs and services, the legislators who approve funding, and the public all have a right to be kept informed of how well we are doing in meeting these challenges. We will develop and produce annual performance reporting for the public and the Legislative Assembly.

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Moving ForwardThe NWT Health and Social Services System will continue to be reliant on other jurisdictions for the delivery of some of our services. Fiscal pressure, as well as, needs and demands of the population require continuous innovation and improvement. Effective collaborative planning is essential in responding to existing and emerging issues. As the need and demand for services increases and the competition for dwindling resources increases, a strategic approach to planning and well thought out actions are essential to meet future challenges. Our Strategic Plan: Building on our Foundation lays out the strategic direction required over the next five years to continue the reform of a fragile system.

The next section of this document details the actions required to achieve our strategic priorities. These actions will be reviewed and updated as necessary to address emerging issues and challenges. Actions identified include targets, deliverables and performance measures and will form the basis of our Business Plans to be presented annually for funding consideration. In order to achieve positive health outcomes and make the necessary reforms to the system, we will need long-term and sustained funding to achieve the actions identified and continue to build on our foundation. Progress towards achieving these actions will be reported on to the public and the Legislative Assembly annually.


Priority 1: Enhance services for children and familiesObjective: Increase capacity of community to care for children and families at risk

Individuals and Families

Access to plain language information and material on the Child and Family Services Act and related programs and services

Target:

Year 1, Plain language materials completed

Year 1 & 2, Translation of material into official languages

Year 2 and ongoing, Provide plain language materials to clients

Year 3, Survey service providers and families to assess level of satisfaction with material

Year 4, Review and amend where required

Deliverable:

NWT residents will have access to plain language information and material to assist them in accessing appropriate programs and services

Communities

Provide support to communities to establish Child and Family Services Committees

Target:

Year 1 and ongoing, Provide training and support to communities to establish 5 committees per year where communities have identified willingness and capacity

Year 3, Evaluate the results of committee initiation to determine if there are barriers where HSS could provide additional support to communities

Deliverable:

While not every community needs or will be able to support a Child and Family Service Committee, our target is to work with communities to support them to initiate at least 20 Committees by the year 2016

System

Propose appropriate amendments to the Child and Family Services Legislative Framework

Target:

Year 1, Legislative Review

Year 2, Standards and Practice Manual redevelopment, provide necessary staff training and compliance reporting

Year 2 to 5, Prepare/propose legislative amendments where appropriate

Deliverable:

Within the life of the 17th Legislative Assembly appropriate amendments to improve the Child and Family Services Legislative Framework will be developed and proposed

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Implement respite support in small communities for individuals and families with children with disabilities

Target:

Year 1, Implement common assessment / case management tool

Year 2, Work with communities to develop a community based respite program

Year 3, Evaluate implementation barriers

Year 4, Identify future needs for family education and training to provide care for family members in homecare and respite support for the future

Deliverable:

There will be a comprehensive Territorial Respite model including standards, policies, procedures, intake assessment tools, and forms. It will also include detail on resource requirements for funding consideration in the 2013/14 Business Plans

Communities

Expand the Healthy Family Program

Target:

Two additional communities with Healthy Family Program a Year

Deliverable:

Ten additional communities in the NWT that offer early childhood intervention initiatives (birth to age 16) and community level support for families

System

Modernize Child and Family Services training available to families, communities, band administrators and providers

Target:

Year 1, Redesign training

Year 2, Offer seven community based training sessions per year

Deliverable:

Families, communities, band administrators and providers will have access to ongoing training in:

• Cultural relevancy and traditional values

• Conflict resolution

• Mediation

• Child Development, resiliency



Provide persons with disabilities appropriate access to sustainable programs and services. Current programs to support persons with disabilities include: Home Care, Respite, Day Programs, Assisted Living Programs, Employability Programs, Rehabilitation Programs, and programming through Child and Family services

Target:

Year 2, Review of existing disability related programs and services including community based supports, territorial services and access to speciality out of territory services

Year 3, Identify opportunities for local, regional and territorial service delivery

• Develop an integrated case management model

Year 4, Implement an integrated case management model

Deliverable:

Services and care for persons with disabilities will be integrated to provide a better continuum of care through a comprehensive case management model

System

Develop Information Sharing Protocols with partners to improve case management

Target:

Year 2, Develop protocols

Year 3, Review protocols

Deliverable:

HSS will have information sharing protocols that will allow work with other departments and organizations such as Education Culture and Employment, NWT Housing Corporation, Justice and the RCMP to improve coordination of supports and services at both the policy and delivery levels

Communities

Provide community education workshops related to the Child and Family Services Act

Target:

Year 1, Develop workshop

Year 2, Offer workshop to willing communities

Deliverable:

All communities will have access to workshops to help increase their knowledge and understanding of the Child and Family Services Act

System

Publish plain language CFS practice standards

Target:

Year 1, Write standards

Year 2, Make publicly available

Year 3, Incorporate into training and public documents

Deliverable:

There will new plain language CFS practice standards to ensure consistent and safe practice

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Communities

Work with communities, to enhance the recruitment of Foster Parents

Target:

Year 1, Develop new recruitment approaches and partners

• Enhance support and training for foster parents

• Implement kinship foster parent supports

Year 2 and ongoing, Recruitment in place

Deliverable:

There will be an enhanced Foster Parent Recruitment Plan in place geared at increasing the number of homes available for foster care placement

Partner with communities to develop culturally appropriate child development and prenatal programming

Target:

Year 1, Establish partnerships and develop programs

Year 2, Implement programs

Year 3, Ongoing

Deliverable:

Communities will have access to culturally appropriate child development and prenatal programming


Performance Measures Baseline 2012/13 Target 2013/14 Target 2014/15 Target

Percentage of children receiving services in their home community

80% 83% 85% 85%

Percentage of children receiving services in their home or with a relative

59% 60% 62% 65%

Number of communities with a Child and Family Services Committee initiated

1 6 10 15

Number of Foster Families in the NWT TBD TBD TBD TBD

Number of NWT communities where respite is available

3 7 10 14

Number of communities with a Healthy Family Program

4 6 8 10

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Priority 2: Improve the health status of the populationObjective: In cooperation with communities and partners, implement health promotion, prevention and self-care activities focusing on individuals most in need.


Access to culturally relevant programs, information and tools to achieve better health outcomes includes:

• STI prevention materials

• Smoking reduction

• Newborn screening

• Prenatal health (FASD, high risk births)

• High risk drinking

• Nutrition and Obesity

Target (ongoing)

• Establish a target for the number of patients (smokers) that receive a “quit smoking plan” from their primary care provider (monitor and report on)

• In collaboration with MACA, develop health promotion activities aimed at keeping youth active

• Incorporate comprehensive prenatal health (FASD information) into ongoing primary care

• Develop and pilot projects aimed at weight loss for parents and their children

Communities

Ensure access to comprehensive mental health and addictions (MHA) services by: increasing public understanding of MHA, integrating MHA programs into primary community care, improving access to services and increasing accountability

Year 1 and ongoing, Work with aboriginal governments to develop action plans that build on existing community assets and resources to provide services that best meet the needs of their community

Year 1, Create a clearly defined referral process within the mental health and addictions system that simplifies access and strengthens coordination

• Reduce barriers to treatment and resources through client-centered approaches

Deliverables:

• Community / Regional specific action plans will be developed

• By the end of year one there will be established referral protocols in place

System

Chronic Disease Management (CDM) Model which integrates mental health into the CDM model

Target:

Year 1, Develop a culturally appropriate CDM model

• Focus action on community based supports for Diabetes, Mental health and renal care

• Develop and implement CDM education and prevention programs

Year 2, Develop a database to track and monitor NWT residents with chronic conditions

Year 3, Expand focus to other chronic diseases

Deliverable:

HSS will have a fully integrated CDM model that incorporates care pathways and outcome measures needed to track system quality


Work with other GNWT departments, NGOs and communities to raise awareness, and reduce occurrence of family violence and elder abuse in the communities

Target:

Year 1, Establish partnerships and develop options for integrated delivery of supports by government and communities

Year 2, Implement

Deliverable:

Increased awareness in communities

Individuals and Families continued...

• Ensure social marketing campaigns geared at STI prevention, smoking reduction and high risk drinking are having an impact on the population.

Deliverable:

Annual public reporting on the number of patients/clients that receive a “quit smoking plan”

Communities continued...

• By the end of year three existing programs will be assessed to ensure they are accessible, non-stigmatizing, comfortable, welcoming and confidential (reducing barriers to obtaining services)

• Staff will be trained in non-violent crisis intervention, suicide intervention, Mental Health first-aid and self-care

• Every two years and ongoing client satisfaction surveys will be conducted and publicly reported on


Build community capacity to prevent and respond to suicide risks, and other mental health events

Target:

Year 1, Collaborate with communities in the delivery of suicide prevention training

Year 2, Ongoing training capacity development and evaluation

Deliverable:

Community capacity to respond to mental health related incidents

Improve communications so individuals and families know how and where to access services

Target:

Year 1, Develop a communication plan and culturally appropriate material in consultation with former clients, NGOs, and providers

Year 2, Implement and assess success

Year 3, Revise where necessary

Deliverable:

Effective communications with the public

In partnership with communities, NGOs Aboriginal organizations and other GNWT Departments further implement the Healthy Choices Framework

Target:

Year 1, Develop actions aimed at encouraging individuals to make healthy choices

• Develop an evaluation framework

Year 2, Partner with NGOs and aboriginal governments to deliver programs and materials

Year 3, Monitor and evaluate

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Deliverable:

Community capacity to deliver appropriate healthy choices initiatives

Work in partnership and provide support to communities, NGOs, Aboriginal organizations and other GNWT departments addressing HSS related prevention initiatives geared at reducing homelessness and poverty amongst high-risk groups

Target:

Year 1, In collaboration with partners, identify HSS actions aimed at improving the overall health and well-being of individuals challenged with issues of homelessness and poverty

Year 2, Implement actions



Self reported health status: % of Northerners reporting “excellent”, or “very good” health

52% (CCHS 2009) 53% 56% 58%

Ambulatory sensitive conditions (chronic disease) as a proportion of overall hospitalizations

4.5% of overall hospitalizations in

2009/2010

4.5% 4.25% 3.90%

Rate of hospitalizations where a mental health issue was the primary reason

11.3 per thousand 2009/10

10 9 8

STI Incidence Rate for Chlamydia, Gonorrhoea, and Syphilis

260 per 10,000 in 2009/10

225 200 160

# of smokers who report being counselled to quit smoking by their primary care provider

43% by Physicians 38% by Nurses

N/A – data not available

52% Reporting on 13/14 data.

Incidence rate of Type II Diabetes in population aged 45-59 years

10 per 1000 2008/2009

9.5 9.0 8.5

Lower limb amputation hospitalization rate among population with diabetes

4.27 (07/08-09/10 avg.)

per thousand patients with diabetes

TBD TBD TBD

Percentage of obese adults in NWT 27%

2009/1025% 20% 17%

Prevalence of smoking (15 years and older)36%

2009 N/A – data not

available25% Reporting on

13/14 data

Prevalence of heavy drinking (15-24 years) 62%

2009 N/A – data not

available30% Reporting on

13/14 data

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Update and modernize the Integrated Service Delivery Model (ISDM) to ensure that residents of the NWT have appropriate access to basic health and social services as needed

Target:

Year 1, Identify and assess barriers under the existing service delivery model

Year 2, Develop and implement a change management plan to fully support the ISDM

Deliverable:

Residents have appropriate access to basic health and social services

Priority 3: Deliver core community health and social services through innovative service delivery

Objective: Through innovative delivery ensure people have the majority of their health and social needs met by high quality community-based support and care

Communities

Develop a Territorial Midwifery program that would allow patients to access safe, quality service as close to home as possible

Target:

Year 1, Develop a territorial model and identify the resources required to implement

• Identify what communities have the appropriate supports to provide safe quality care

• Develop a recruitment and retention plan for hard to recruit positions

Year 2, Develop an implementation plan

Year 3, Ongoing implementation and evaluation

Deliverable:

Patients have access to safe, quality midwifery services

Systems

Develop a Territorial Support Network (TSN) based on networks of pooled expertise to support care providers in the field and provide oversight and expertise for medical evacuations and travel. This will include a virtual clinic to ensure ongoing support

Target:

Year 1, Pilot TSN

Year 2, Review and assess based on the pilot

Year 3, Begin full implementation

Deliverable:

A support-centre with experienced staff who provide consultations and make referrals as required and are the connection to medical travel



Training and support to allow families to care for individuals and loved ones in their homes where appropriate. This includes homecare that responds to higher acuity discharged patients as well as allowing seniors to age in place and palliative care

Target:

Year 1, Identify training needs and existing supports in the communities

Year 2, Implement training

Year 3, Ongoing training and evaluation

Deliverable:

Residents have access to care in their home

Communities

Partner with communities, voluntary sector and aboriginal organizations to develop home care support for individuals to remain in their homes and home communities for as long as possible

Target:

Year 1, Identify training needs and existing supports in the communities

Year 2, Implement training

Year 3, Ongoing training and evaluation

Deliverable:

Residents remain in their home for as long as possible

Systems

Implement actions and changes required to allow homecare to respond to early discharge from southern hospitals and NWT acute care facilities. As well as assisting seniors to age in place

Target

Year 1, Identify required resources and actions

Year 2 and ongoing, Implement

Deliverable:

Residents remain in their home for as long as possible

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Ensure that residents of the NWT are protected from injury and disease

Target:

Year 2, Produce and publish a comprehensive Territorial Injury Report that will inform the development of strategies to promote and improve injury prevention

• Provide support to families for greater role in controlling infections such as MRSA & TB

Deliverable:

There will be fewer preventable injuries and deaths and a decrease in the incidence of preventable disease

Communities

Build capacity to ensure that residents of the NWT are protected from injury and disease including the capacity to control infections such as MRSA and TB

Target:

Year 2, Work in partnership with communities and non-government organizations to develop strategies to respond to and prevent injury and disease

• Work with communities and other government departments to review and enhance emergency planning

Year 3, Develop infection control supports and culturally appropriate material in consultation with community groups, NGOs, administrators and providers

Year 4, Implement and assess success

Deliverable:

Community capacity to deliver injury prevention strategies

Systems

Integrate and modernize consistent standards, policies, best practices and decision making tools across the system. May include Community Health Nursing standards, management of chronic disease, renal dialysis, continuing and long term care standards, and clinical standards

Target:

Year 1, Gap analysis of existing standards and policies

Year 2, Identify resources required and develop a staged approach plan to complete the work

Year 3, Modernize and develop required standards and policies according to plan

Year 4, Implement standards and training

• Develop and implement a compliance monitoring framework

Deliverable:

Existence of updated standards, policies and tools


Systems continued...

Continue to use technology such as Telehealth, DI/PACs and electronic health records, to improve access to specialists

Connect patients and local care providers with a virtual team to enable service delivery in home communities

Target:

Year 1, Develop a comprehensive IT Strategic Plan

Year 2, Identify resources and actions required and begin implementation

Year 3 and ongoing, Implement, assess and upgrade

Deliverable:

Improved access to specialists

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Injury –prevalence of falls in hospitals TBD TBD TBD TBD

Reduced hospitalizations due to injury TBD TBD TBD TBD

# of standards reviewed and implemented

TBD TBD TBD TBD

Percent of clients receiving home care in their community

TBD TBD TBD TBD

Incidence of active turberculosis 2.7 per 10,000 population

in 2008/10 TBD TBD TBD

Number of clinical Telehealth clients Increase by 5% per year


Priority 4: Ensure one territorial integrated system with local deliveryObjective: Ongoing sustainability of the system and best value for money


Appropriate access to services through a comprehensive and modern GNWT medical travel system and policy

Target:

Year 1, Medical travel business process implementation

Year 2, Standards / policy development regarding escort support, patient per diems, translation, efficiencies and medical evacuations

Year 3, Medical travel governance and decision making organizational structure implemented

Year 4, Medical travel case management system in place

Deliverable:

Clients receive appropriate access to medical travel

Communities

Establish appropriate governance and accountability structures through role clarification, appropriate financial and accountability agreements and grants and contribution programs

Target:

Year 1, Include expected delivery standards in contribution/funding agreements

• Amend NGO agreements to focus on and fund outcomes

Year 2, Establish best practices and revise existing policies

• Deliver training for service delivery partners

Deliverable:

Appropriate governance and accountable structures are in place

System

Establish an NWT system governance and accountability structure to ensure system leadership, risk management and accountability which links with GNWT and ensures a one system approach

Target:

Year 1, Review existing policies and contribution/funding agreements

Year 2, Establish best practices and revise existing policies and implement

Year 3, New contribution/funding agreements

Year 4, Ongoing compliance and performance monitoring

Deliverable:

Public reporting on system accountability

26

System continued...

Infrastructure planning to ensure modern and safe facilities and medical and other equipment that meet current infection control standards and promotes efficient service delivery. This includes:

• Support for information technology;

• Biomedical equipment;

• Small capital equipment; and

• Ongoing renovations and upgrades to facilities

Deliverable:

Facilities are renovated according to budget and medical equipment meets approved standards

System continued...

Support Human Resources in developing a comprehensive recruitment plan for the HSS system including a service level agreement for recruitment and retention processes and activities that clearly sets out roles and responsibilities, timelines, and services to be delivered

Target:

Service level agreement between HR and the HSS system

Deliverable:

Service level agreements are in place

Develop and implement appropriate governance and accountability structures for medical travel linked with back office service delivery

Targets:

Year 2, Redesign protocols for care and treatment called “clinical care pathways” based on best practice to help patients move seamlessly through the system

Deliverable:Improved economic stability and patient experience

System continued...

A modern Legislative Framework that supports the mandate of the NWT health and social services system:

Target:

Over the life of the 17th Legislative Assembly we will develop, review and propose amendments/updates as follows:

• Health and Social Services Umbrella Profession Act including Regulations

• Mental Health Act

• Hospital Insurance and Health and Social Services Administration Act and the Medical Care Act

• Health Information Act and regulations

Deliverable:

A modern and updated legislative framework



Percentage of total biomedical equipment replaced based on recommended life cycles

5% (2011/12) 6% 12% 12%

Percentage of total value HSS Centres scheduled for major upgrade or replacement

1.5% (2010/11) 2% 3.5% 6%

Time it takes to staff a position 6 months 5 4 3

Percentage of total bed days as alternative level of care

7.9% (2009/10) 7% 6% 5%

No shows for Medical Travel TBD TBD TBD TBD

No shows (Specialists) 11% (2010/11) 10% 8% 5%

No shows (Family Practitioner & NPs) 9.8% (2010/11) 9% 8% 7%

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Priority 5: Ensure patient/client safety and system qualityObjective: Build territorial and local capacity to ensure safety and quality of care


Ensure that individuals and families are informed of their role in accessing treatment and care and the role of family in supporting individuals undergoing treatment or care

Year 1, Disseminate plain language information for the public on palliative care and the role of the family and personal directives

Year 2, Develop Regional supports for palliative care

Deliverable:

Individuals and families are provided with appropriate information on treatment and care

Communities

Enhance retention of qualified staff by working with communities and partners to ensure that front line health and social services workers are provided with a safe and welcoming environment in which to work and live

Deliverable:

Increase staff recruitment and retention

System

Update and modernize the Integrated Service Delivery Model (ISDM) to ensure that residents of the NWT have appropriate access to basic health and social services as needed

Target:

Year 1, Review and realign the resources under the existing service delivery model

Year 2, Develop and implement a change management plan to fully support the ISDM

• Amend funding agreement based on the ISDM

Deliverable:

Residents have appropriate access to basic health and social services as needed


System continued...

Develop and implement a pharmacy strategy to improve management of drugs and other pharmaceuticals

Target:

Year 1, Develop and implement

Deliverable:

A pharmacy strategy is developed and implemented to reduce costs and increase efficiencies.

System continued...

Complete and implement an accountability framework for patient safety across authorities to ensure ongoing improvement of patient care

Target:

Year 2, Review of best practices

• Develop and implement a reporting and information sharing mechanism

Deliverable:

A reporting mechanism that ensures ongoing quality improvement and best practices.

System continued...

Improve territorial standards for prevention and control of infections in health-care facilities. Build system capacity and oversight

Target:

Year 2, Define minimum competencies and skill sets for practitioners

• Review and modernize existing infection control standards and standards for sterilization.

• Implement a surveillance system for reportable infections

• Develop and implement reporting and compliance mechanism

Deliverable:

Health care facilities have improved infection control standards

30

Performance Measure Baseline 2011/12 Target 2012/13 Target 2013/14 Target

Incidence of community acquired MRSA

28 new cases per 10,000 2009/10

TBD TBD TBD

The percentage of employees that indicate they feel safe and supported in their work environment

TBD TBD TBD TBD

Reduce the rates of hospital-acquired infections

TBD TBD TBD TBD

Timeliness of response to identified adverse events

TBD TBD TBD TBD


Priority 6: Outcomes of health and social services are measured, assessed and publicly reportedObjective: Ensure accountability of the system by reporting to the Legislative Assembly and the public.


Monitor and report on client and patient satisfaction with their access to and experience with the health and social services system

Target:

Ongoing client satisfaction surveys and reporting of results

Deliverable:

Increased accountability reporting to the public through ongoing client satisfaction surveys

Communities

Improved monitoring and reporting of information

Target:

Ongoing public reporting of the performance results of the NWT health care system

Deliverable:

Health and Social Services System Annual Report

System

Address the data compatibility issue and increase capacity for data collection, analysis, monitoring and reporting. This will allow HSS to monitor the performance of the system and publicly report

Develop HSS performance indicators that will be tied into the performance agreements with the Authorities

HSS will also develop a program evaluation plan as directed by the Office of the Auditor General. The evaluation plan will have a risk-based lens and tie into the Department’s Risk Management Plan

Target:

Year 1, Review existing data sources and identify the gaps

• Develop a public report for HSS performance measures (Balanced Scorecard)

• Develop a program evaluation plan

Deliverable:

Outcomes are measured, assessed and publicly reported on

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Performance Measure 2009/10 Baseline 2011/12 Target 2012/13 Target 2013/14 Target

Percentage of residents satisfied with overall health services

86% 87% 90% 92%

Data collected and outcome measures reported on for the Balanced Scorecard

N/A Data Collection Reporting on performance

measures

Degree to which mental health and addictions services meets the needs of clients

98% (2007/08) 98% 98% 98%

building on our foundation 2011-2016 - northwest territories · building on our foundation 2011-...

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